Cervicogenic headache: Location and source

By Jan Willem Elkhuizen

Where is the headache located?

The place where the headache is precisely localized can be an indication of the location of the cause. There are three types of experiences that provide an image here:

• Experiments in which headache patients are treated with local injections of an anesthetic. The place where the pain subsides is marked and linked to the tissue that is anesthetized.
• Experiments in which healthy people are injected with a stimulating substance. The pain that then arises is linked to the injection site.
• Experiences of doctors and therapists in treating headache patients. If the pain subsides after treatment of, for example, a muscle or joint, this can be an indication that the source of the pain was indeed identified. Of course, there are placebo and other effects, but in the long term and with sufficiently large numbers, these practical experiences lead to more insight.

Based on the available data, the following picture can be sketched.

A. Pain stimuli from the soft tissues (muscles, tendons, attachments, etc.)

Explanation:
C0-1: Between the skull and the 1st vertebra (the atlas)
C1-2: Between the 1st and 2nd vertebra (atlas and axis)
C2-3: Between the 2nd and 3rd vertebra
C3-4: Between the 3rd and 4th vertebra

There is a lot of overlap. Roughly, the trend is: The higher the source, the higher the pain ('higher' = more towards the forehead). The pain is basically one-sided, unless multiple muscles etc. are affected.

N.B.: The above image is derived from experimental research on healthy individuals in whom a pain-inducing substance was injected.

B. Pain stimuli from the joints

The projection area of the pain depends on the severity and the duration of the stimulation. As the complaints persist longer, the area of complaints often gradually expands.

With mild stimulation by injection of pain-provoking substance into the upper neck joints in healthy subjects, the expansion area is limited:

With persistent stimulation, the pain in patients can increase significantly and the area where the pain is felt becomes larger. This applies to all three segments. Below are some examples of pain areas reported by patients with chronic headache from the neck:

Pain from the neck joints is basically one-sided, unless both joints (left and right) of a particular segment are affected.

C. Combinations of pain areas

There appears to be a lot of overlap in the pain areas from the different sources. This makes diagnosing based on the nature and location of the headache difficult. Additionally, a dysfunction within the C0-2 complex can also lead to dysfunctions in the other joints within that complex, along with the associated complaints. This makes it even less clear.

On top of that, there are the soft tissues. Dysfunction leads to changes in muscle tension, which can cause irritation of muscles, tendons, attachments, etc. When a patient visits a healthcare provider with their complaints, it is often a combination of tissues that together form the source of the complaints.

Underlying causes of cervicogenic headache

(Para)medical professionals have traditionally been accustomed to tracing a complaint back to the anatomical source. This could be a tendon (inflammation), a muscle (tear), an intervertebral disc (hernia), etc. Given the above, it is often difficult, if not impossible, to attribute cervicogenic headache to just one specific source. This is not surprising, as experience shows that often multiple tissues are irritated simultaneously.

More useful than knowing exactly which muscle or joint is irritated is understanding what caused that irritation. By stepping back further than the 'anatomical source,' a better understanding of cause-effect relationships can be gained. Muscles do not become hard without reason, joints do not become stiff without cause.

Although the anatomical source varies, there is generally a connection between some common stressful situations and the clinical picture that results.

I Overuse of the C0-2 complex

A. In forward direction

This occurs with:

• Schoolchildren who read while bent forward a lot
• Incorrect working postures
• Watching TV while slouched on the couch
• Watching TV in bed
• Reading in bed or reclining on the couch
• Sleeping on the back with a pillow that is too high

This often leads to:

• Symmetrical symptoms (left and right sides have roughly equal symptoms)
• Pressure in the head
• Band around the head
• Gradual increase of pressure in the head leading to chronic severe headache
• Looking upwards is often somewhat difficult and uncomfortable
• Dizziness

Two examples of pain areas (if bilateral) that match these symptoms:

In the initial phase, there is not much headache yet, and the sensation is sometimes difficult to describe. Terms used include: a vague, dull feeling in almost the entire head. Notably, mobilization of the C0-2 complex, especially C0-1, often has an immediate effect on the symptoms. The headache usually subsides quickly, but sometimes there is a temporary worsening. After some time, the symptoms return if the underlying causes are not resolved.

B. In lateral direction

.

This occurs with:

• Reading on the side with hand under the head
• Watching TV in side sleeping position
• Pillow too high or too low in side sleeping

This leads to a less clear symptom picture than that of IA and II. Both symmetrical and asymmetrical complaints can result. The type of complaints is also varied and not easily summarized. Notably, mobilization of the C0-2 complex, especially lateral movement, quickly temporarily improves the complaints. However, if the underlying causes are not resolved, the complaints quickly return.

II Overuse of C2-3

This occurs with:

• Sleeping in the stable side position
• Pillow too high (in combination with stable side sleeping)

This often leads to:

• Asymmetrical complaints (one-sided or one side clearly worse than the other)
• Pain 'shoots' from high in the neck up to above the eyes
• Pain above the eyes, with only minor and sometimes no neck complaints at all
• Turning is sometimes slightly limited and a slight 'pulling sensation' occurs in the neck muscles

Notably, the complaints usually respond immediately to mobilization of C2-3. It also applies here that the complaints quickly return if the underlying causes are not resolved.

Two examples of pain areas that correspond to these complaints:

The article 'Sleep positions anatomically considered' goes deeper into the anatomical consequences of incorrect sleep positions and provides more insight into the outlined symptom picture.

See also the pdf of the article on cervicogenic headache.